Configuration of vascular services: a multiple methods research programme

Abstract

Background Vascular services is changing rapidly, having emerged as a new specialty with its own training and specialised techniques. This has resulted in the need for reconfiguration of services to provide adequate specialist provision and accessible and equitable services. Objectives To identify the effects of service configuration on practice, resource use and outcomes. To model potential changes in configuration. To identify and/or develop electronic data collection tools for collecting patient-reported outcome measures and other clinical information. To evaluate patient preferences for aspects of services other than health-related quality of life. Design This was a multiple methods study comprising multiple systematic literature reviews; the development of a new outcome measure for users of vascular services (the electronic Personal Assessment Questionnaire – Vascular) based on the reviews, qualitative studies and psychometric evaluation; a trade-off exercise to measure process utilities; Hospital Episode Statistics analysis; and the development of individual disease models and a metamodel of service configuration. Setting Specialist vascular inpatient services in England. Data sources Modelling and Hospital Episode Statistics analysis for all vascular inpatients in England from 2006 to 2018. Qualitative studies and electronic Personal Assessment Questionnaire – Vascular evaluation with vascular patients from the Sheffield area. The trade-off studies were based on a societal sample from across England. Interventions The data analysis, preference studies and modelling explored the effect of different potential arrangements for service provision on the resource use, workload and outcomes for all interventions in the three main areas of inpatient vascular treatment: peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. The electronic Personal Assessment Questionnaire – Vascular was evaluated as a potential tool for clinical data collection and outcome monitoring. Main outcome measures Systematic reviews assessed quality and psychometric properties of published outcome measures for vascular disease and the relationship between volume and outcome in vascular services. The electronic Personal Assessment Questionnaire – Vascular development considered face and construct validity, test–retest reliability and responsiveness. Models were validated using case studies from previous reconfigurations and comparisons with Hospital Episode Statistics data. Preference studies resulted in estimates of process utilities for aneurysm treatment and for travelling distances to access services. Results Systematic reviews provided evidence of an association between increasing volume of activity and improved outcomes for peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. Reviews of existing patient-reported outcome measures did not identify suitable condition-specific tools for incorporation in the electronic Personal Assessment Questionnaire – Vascular. Reviews of qualitative evidence, primary qualitative studies and a Delphi exercise identified the issues to be incorporated into the electronic Personal Assessment Questionnaire – Vascular, resulting in a questionnaire with one generic and three disease-specific domains. After initial item reduction, the final version has 55 items in eight scales and has acceptable psychometric properties. The preference studies showed strong preference for endovascular abdominal aortic aneurysm treatment (willingness to trade up to 0.135 quality-adjusted life-years) and for local services (up to 0.631 quality-adjusted life-years). A simulation model with a web-based interface was developed, incorporating disease-specific models for abdominal aortic aneurysm, peripheral arterial disease and carotid artery disease. This predicts the effects of specified reconfigurations on workload, resource use, outcomes and cost-effectiveness. Initial exploration suggested that further reconfiguration of services in England to accomplish high-volume centres would result in improved outcomes, within the bounds of cost-effectiveness usually considered acceptable in the NHS. Limitations The major source of evidence to populate the models was Hospital Episode Statistics data, which have limitations owing to the complexity of the data, deficiencies in the coding systems and variations in coding practice. The studies were not able to address all of the potential barriers to change where vascular services are not compliant with current NHS recommendations. Conclusions There is evidence of potential for improvement in the clinical effectiveness and cost-effectiveness of vascular services through further centralisation of sites where major vascular procedures are undertaken. Preferences for local services are strong, and this may be addressed through more integrated services, with a range of services being provided more locally. The use of a web-based tool for the collection of clinical data and patient-reported outcome measures is feasible and can provide outcome data for clinical use and service evaluation. Future work Further evaluation of the economic models in real-world situations where local vascular service reconfiguration is under consideration and of the barriers to change where vascular services do not meet NHS recommendations for service configuration is needed. Further work on the electronic Personal Assessment Questionnaire – Vascular is required to assess its acceptability and usefulness in clinical practice and to develop appropriate report formats for clinical use and service evaluation. Further studies to assess the implications of including non-health-related preferences for care processes, and location of services, in calculations of cost-effectiveness are required. Study registration This study is registered as PROSPERO CRD42016042570, CRD42016042573, CRD42016042574, CRD42016042576, CRD42016042575, CRD42014014850, CRD42015023877 and CRD42015024820. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.

Varicose veins treatment in England: population-based study of time trends and disparities related to demographic, ethnic, socioeconomic, and geographical factors

“…Coding of procedures and other information is restricted and may change over time. In identifying and classifying procedures there may be conflicting or non-specific codes, and the algorithms used to deal with such circumstances have been developed and described elsewhere 3 . Some codes may cover several different procedures, such as those for sclerotherapy, which may be for axial veins or tributary treatment.…”

“…Studies have found the treatment of symptomatic VVs to be both clinically effective and highly cost-effective in the terms usually used by the NHS 3 , 9 , 25 , 26 . Despite national guidance from NICE having accepted this, and having recommended interventional treatment for symptomatic people, the condition is considered relatively minor and therefore has become an easy target for rationing.…”

“…A data extract of hospital episode statistics (HES) from NHS Digital, covering the financial years from 2006/7 to 2017/8, was processed, and classified as part of a larger study of vascular services. The methods for categorization and cleaning of data have been described elsewhere 3 . Day-case and inpatient admissions for VV treatments were identified within the data extract and categorized as open surgery, endovenous laser treatment (EVLT), radiofrequency ablation (RFA), sclerotherapy, and avulsions only.…”

“…Over the past 15 years there have been many changes affecting the surgical management of VVs in England. Policy and organizational changes have included the centralization of vascular services 3 , changes in the commissioning arrangements 4 , and the introduction of independent sector treatment centres 5 . Changes in clinical practice have resulted from the introduction of new endovascular technologies 6 , emerging research evidence from large, randomized studies 7–10 , and the publication of National Institute for Health and Care Excellence (NICE) guidance 11 .…”

“…A previous study of the provision of vascular services in England has identified some of the changes that have resulted from the centralization of services for major vascular surgery 3 ; however, it also suggested that this has had knock-on effects, in that it has influenced the delivery of investigations and more minor procedures that have tended to follow the centralization of major surgery, potentially affecting the local availability of these services. In the context of rapid changes in practice and policy, and varying local guidance, there is a risk that barriers to referral and treatment will lead to disparities in access, clinical practice, and outcomes, based upon demographic, socioeconomic, ethnic, or geographical factors.…”